Linda,
Yes, I would love to hear more from Cathy Genna on babies learning to nurse,
even older babies. Cathy, everything you contribute is so noteworthy!
Linda, you wrote "One mother had a little 36 week infant who got very
jaundice and lost weight etc. ... another with small infant and mom has
large nipples, again lost over a pound." and then asked "we have worked on
plans for getting back to breast but... any wisdom would be helpful.  What
works, what mental steps do you take"
Of course this is the *$64 question* as we say in the USA! What I have
realized is that alternate feeding has to begin very quickly. This is always
a judgement call because one never is really sure how much and how soon and
whether the baby will get it together if just a couple more hours are
allowed to pass. While I know that some well babies and babies that will be
successful breastfeeders can sleep and not need to eat for hours and hours,
these are usually babies that had a good feed at birth and then slept w/
mommy for a long while (not separated) and then woke on their own time to
feed again. What I have found in a non-Baby Friendly hospital (far from it)
is that when a baby has not had a good first feed soon after birth and has
not had a good feed w/ a skilled bf helper, then go ahead and start the
frequent expressing and alternate feeding. Unfortunatley I find that formula
is frequenlty needed in these cases, as moms more often than not express
very small quantities and babies continue to lose wt and their bili levels
rise.
I worked w/ a mom this week w/ a 36 wk-er, 4#12 oz. The baby was not feeding
effectively but was latching. The mother was expressing very small amounts
like 5-6cc every 3 hrs. This was mixed w/ sterile glucose water to make up
to about 15cc. The pediatrician was ok w/ this and so was I and after 24 hrs
the baby went down to 4#9 and looked jaundiced. The 2nd day the baby was not
doing much better as far as feeding effectiveness and the mother was not
expressing much more volume and the baby went down to 4#6 and the bili was
15. The formula was started then and so was phototherapy and mother/infant
separation for that treatment. (they do not do in-room treatment or home
treatment). It was a judgement call to let the baby continue the 2nd 24 hrs
and the pediatrciian was ok w/ it but I *knew* from expereicne that the baby
would lose more weight and get jaundiced.
What I always ask myself (and have asked lactnet) - what is worse? 1. to
lose the weight and increase the bili  vs. 2. to get the formula? I don't
have the answer but a baby who can't latch or can't suckle effectively does
not represent a normal bf picture, so interventions are needed.  This is
what I have come to conclude and the sooner the interventions the better.
Sorry so long and hope this makes sense.

Laurie Wheeler, IBCLC, MN, RN
New Orleans Louisiana, s.e. USA

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